Defining the subtleties of grief

Gloria Ciaccio, who lost both of her parents within a year of each other, made memorial gardens for them in her backyard. (Jose M. Osorio, Chicago Tribune)

In the weeks after her mother's death, Gloria Ciaccio was steeped in grief. Numb and shocked, Ciaccio cried a lot, fought the urge to call her late mom on the phone, and felt like doing absolutely nothing.

But though overwhelmingly sad, Ciaccio was not suffering from clinical depression, a mood disorder that often requires treatment. Like most cases, her grief gradually and naturally lifted over time.

The subtle distinction between acute grief and major depression, which is often difficult to make, is at the heart of a long-running and contentious debate in the psychiatric world. Grief-stricken patients frequently report symptoms that are also typical of major depression, such as sadness, tearfulness, insomnia and decreased appetite.

But grief rarely produces the disabling symptoms of depression, such as low self esteem, feelings of worthlessness, delusions, inability to function and suicidal thoughts.

Now, a controversial change to the reference guide used by psychiatrists, called the Diagnostic and Statistical Manual of Mental Disorders (DSM), makes it easier to diagnose depression in those who are also grieving.

The latest edition, called DSM-5, characterizes bereavement as a severe psychological stressor that can incite a major depressive episode in as little as two weeks after a loss.

Critics say this revision will pathologize grief, a normal human condition, resulting in the excessive and costly use of medication. "We should expect mourning. We should treat melancholy," said Dr. Allen Frances, chair of the task force that produced the previous revision, called the DSM-IV and one of the fiercest critics of the change. "The DSM-5 has blurred the already fuzzy distinction," he said.

But supporters of the change to the guidelines, which influence treatment and insurance decisions and can affect the lives of millions of people, say the revision opens the door to help a vulnerable group whose needs have previously been ignored.

"Grief doesn't really end," said Dr. Sid Zisook, professor of psychiatry at the University of California at San Diego, whose research examines the differences between grief and depression. "My work would never indicate that I think it should end in two weeks. But can you diagnose depression in a vulnerable person who is also bereaved? That isn't easy but it can be done (in two weeks)."

The older version of the manual included a bereavement "exclusion", which meant that in most cases clinical depression would not be diagnosed if it occurred within the first two months after the loss of a loved one. Instead, it would be labeled "bereavement."

The exclusion has been dropped because "all the research suggested that if a major depression occurred in the context of a death of a loved one, the patient would have the same morbidity and negative consequences of major depression occurring in the context of any other severe life event, or even if no 'trigger' could be identified," Zisook said.

Frances, the author of the book "Saving Normal," which details the controversy over psychiatric diagnoses, agrees that severe depression should be immediately treated if it occurs while someone is also grieving. But he also believes the change allows drug companies to market grief as "major depressive disorder."

"The problem arises because milder depressions are completely indistinguishable from normal grief," he said. "The DSM threshold for mild depression is particularly low. Often what DSM calls 'major depressive disorder' is not major, depressive or a disorder."

Frances, who is professor emeritus and former chair of the Department of Psychiatry and Behavioral Science at Duke University School of Medicine, worries that primary care doctors who spend very little time with their patients will be the ones prescribing anti-depressants to grief-stricken patients, rather than psychiatrists.

"If, for two weeks after losing the love of your life, you have sadness, loss of interest, trouble sleeping and eating and less energy, the DSM-5 now allows a drug salesman to teach the doctor that this is major depressive disorder and requires a pill," he said.

"In fact we're cheapening the human experience of grief and substituting a superficial medical ritual for the deeply held and revered customs that all cultures have for dealing with the departed."

Still, both Frances and Zisook agree that asking whether someone is experiencing "grief" or "depression" is the wrong question. Instead, "'the real question is whether the symptoms go beyond what is expected, how impairing they are, and whether there is a risk of suicide," Frances said. "For most of the bereaved, grief is the necessary price of having loved and lost."